An assessment of publishing practices and barriers faced by medical students to conduct research: A cross‐sectional study from Pakistan

Abstract Background Pakistan being a low‐ and middle‐income country, its institutes are substantially deficient in scientific and technological aspects and share limited research contributions to the world repositories. Therefore, there is a rising concern to reflect on the history and status of publishing attitudes among medical students in Pakistan and to highlight and address the barriers that they are facing. Methods A study was conducted aiming to determine the experience, motivation, and attitude of medical students in regarding publishing practices throughout Pakistan in several medical colleges. A multivariable logistic regression model was used to find the independent predictors of students publishing a research article. Forward selection was used to arrive at the final stepwise logistic regression. Odds ratio (OR) and 95% confidence interval (CI) were calculated. p < 0.05 was considered significant for all statistical tests. Results From a sample size of 1225 participants, only 6.6% of students had published an article in our study. Of these, 59% were males and 31.3% were in final year. Males were more likely to publish articles than females (OR = 2.69, 95% CI: 1.37–5.26) and final‐year students were more likely to publish articles than first‐year students (OR = 7.48, 95% CI: 1.34–41.81). Students that had the knowledge that performing research is the way through which they will be judged for jobs had significantly higher odds of getting an article published (OR = 16.21, 95% CI: 3.65–71.88). Additionally, students who had been taught how to write a paper and those who knew the process of submitting an article were more likely to get published than the others. Conclusion Our study has successfully highlighted the status of publishing among medical students in Pakistan. Our findings serve as an eye opener and call to action for authorities to address the grievances of students in terms of barriers, lack of mentorship, and lack of research teaching. We hope our findings can guide a strong policy change to facilitate the next generation of passionate researchers.

Conclusion: Our study has successfully highlighted the status of publishing among medical students in Pakistan. Our findings serve as an eye opener and call to action for authorities to address the grievances of students in terms of barriers, lack of mentorship, and lack of research teaching. We hope our findings can guide a strong policy change to facilitate the next generation of passionate researchers.  1 It also bolsters medical students' critical thinking skills, ability to explore literature, teamwork, and writing skills. 2 Furthermore, performing research at an undergraduate level, not only maintain the student's attitude toward doing research throughout their course of study but also ease one's chance to make a career in the field of medicine. 3 In addition to the latter publishing, is now a form of assessing career and selfdevelopment to recruit the doctors in this era of amplified competition than before. 3 Notably, the trustworthiness, respect, and ranking of higher education institutions (HEI) are primarily determined by their academic integrity and their status in publishing ethical scientific research. Hence, academic institutions from high-income countries are continuously striving to enhance the quality of education and research to eventually nurture their ranking and prestige. 2 As reported by the study of Kanwal Ameen, most of the world's scholarly communication is concentrated in a few HIC that are scientifically equipped with technologies such as, that is, United States, United Kingdom, and other European countries. On the contrary, HEI of low-and middle-income countries (LMICs) is not only behind in deliverance of quality education but also in promoting research publishing. 4 Considering, Pakistan, is the fifth most populous country in the world after China, India, the United States, and Indonesia. 5 Further, its annual intake is about 15,000 medical students. Out of almost 3000 medical colleges in the world, there are around 114+ medical colleges in the state, with around 38% public and 62% private. At the provincial level, Sindh and Punjab, and the Federal area own around more than 50% of medical colleges remaining covered by other provinces of the state, that is, Baluchistan, Khyber Pakhtunkhwa (KPK), and Azad Jammu and Kashmir (AJK). 6 Pakistan being an LMIC its HEIs are substantially deficient in scientific and technological aspects and share limited research contributions to the world repositories also. 7 Therefore, there is a rising concern to reflect on the history and status of publishing attitudes among medical students in Pakistan. To understand where it stands today and what needs to be done to upgrade it. Thus, to the best of our knowledge, this study is the first to assess the publishing practices of Pakistan medical students to investigate potential barriers to performing research and submitting papers.

| METHODS
A study was conducted aiming to determine the experience, motivation, and attitude of medical students regarding publishing practices. This study was conducted throughout Pakistan in several medical colleges. Any medical student falling under the age group between 18 and 30 years was eligible to participate in the study. No specific gender or ethnic group was given significance.
Ethical approval was taken from Faisalabad Medical University, Faisalabad. Informed consent for voluntary participation was taken from the participants after declaring the study objectives at the start of the questionnaire. Respondent anonymity and confidentiality were insured by design. The guidelines outlined in the Helsinki declaration were followed in this study.
To collect data, an online questionnaire on Google Forms was circulated among medical students across Pakistan through social media. The questionnaire was previously constructed and used by other researchers (3) and was modified to suit our objectives. The validity of the questionnaire was checked by Cronbach alpha which was greater than 0.7. The first section of the questionnaire was about basic demographics of the participant. The second section was based on experiences in the field of research and contained questions regarding motivation behind writing a paper and factors contributing to choosing a journal for publication. The third and fourth sections were more specifically related to past expertise in research and attitudes toward publishing.

| Publishing status of students
Only 6.6% of students had published an article in our study. Of these, 59% were males and 31.3% were in final year (Table 1). Males (10.1%) were more likely to publish an article than females (4.4%; Pearson's Chi-Square test, p < 0.001). Year of study was also significantly associated with whether students published articles with final year students publishing more articles (32.5%; Pearson's Chi-Square test, p < 0.001). Of the students that had published articles, the type of article, their author rank, and the outcome of their submission varied ( Table 2). The principal motivation behind publishing articles was highlighted as improvement of resume (24.6%) and interest (26.2%; Figure 1). When asked which factor affected their choice of journal the most, 32.2% said it was the journal repute while 23.5% said it was the possibility of acceptance. The main hindrances to not publishing an article were stated as lack of guidance and supervision (31.6%), not having the opportunity to take part in research (30.5%), and being not interested (23.8%) by the students (Figure 2).

| Research participation of the students
The vast majority of the students (70.4%) had not taken part in either a research project or an audit and only 25.9% and 1.7% had taken part in a research project and an audit, respectively; of these, 90.6% had taken part in less than 5 research projects or audits. Most of these projects were questionnaire-based (64.1%). Of the students that had taken part in research, 53.9% stated that they had conducted projects in the career they wished to pursue.

| Teaching and opportunity to take part in research
Majority of the students said that they would like more opportunity to take part in research or audit projects (73.4%). Only 9.0% wanted to take part in laboratory research while the rest indicated that they would like to participate in clinical research. Most of the students felt that they had not been encouraged by their seniors to get involved in research (66.0%). A large proportion of students wanted to take part in research in any area just to gain experience (40.6%) while 34.9% only wanted to take part in their specialty of interest. Eighty percent of the students had never applied for ethical approval for a research project.

| Journal reading, presentations, and posters
Fifty-seven percent of the students read journal articles with most of them stating that it was either for interest (35.9%) or to improve their knowledge (48.5%). The major reasons for not reading journal articles were not being encouraged to do so (33.7%) and not being interested (31.5%). Only 10.1% had submitted an abstract to a scientific conference. Forty-six percent had presented a poster or given an oral presentation at a conference. Only 36.7% of the medical students said that they were encouraged by their seniors to get involved in presenting at a medical conference.

| Teaching received on writing papers
Only 18% of the students said that they knew how to critique a paper. Thirty percent of the students felt that they could write an abstract while 60.4% felt that they knew how to write a paper. Only 17.7% and 26.4% of the students had been taught how to write an abstract and paper, respectively. Regarding the publishing process, 19.8% stated that they knew how to submit an article while only 25.0% were confident of submitting an article without supervision.
Thirty-five percent of the students wanted to be taught how to write an abstract, 40.5% for a paper and 51.1% wanted teaching on publishing practices. The majority of the students felt it was important to publish a paper (73.4%) with the main reasons being to improve their career (41.7%) and it is an important skill to learn (34.1%).

| Knowledge in the importance of publishing
Overall, 60.2% of the students knew that they are expected to have taken part in research projects during their time at the medical school. A similar proportion of students (59.1%) said that they knew that submitting papers and performing research is the way through which they will be judged for jobs later in their careers. Fifty-eight percent agreed that the survey has convinced them to begin seeking opportunities to perform research or audits.

| Barriers to publishing
Stepwise logistic regression model showed that males were more likely to publish articles than females (OR = 2.69, 95% CI: 1.37-5.26) and final-year students were more likely to publish articles than first- year students (OR = 7.48, 95% CI: 1.34-41.81). Students that had the knowledge that performing research is the way through which they will be judged for jobs had significantly higher odds of getting an article published (OR = 16.21, 95% CI: 3.65-71.88). Additionally, students who had been taught how to write a paper and those who knew the process of submitting an article were more likely to get published than the others (Table 3).

| DISCUSSION
In our study of 1252 participants, we found that only 6.6% of students had published an article in our study which is an alarmingly low percentage. Our reported percentage was less than that of previous studies conducted in both HICs; Britain (14%), 3 Sweden (15%), 8 LMICs India (17.4%), 9 Uganda (22.5%), 10 and Nigeria (34.3%). 11 We found gender disparities in the publishing practices; males formed 59% of students who had an article published. We found that being from the male gender made it more likely 10.1% versus females 4.4% to get articles published. These gender choosing clinical practice over academia). 17 Educationalists need to address these gender imbalances by having a targeted approach toward women; providing research incentives to increase participation and increasing the availability of gender-specific mentorship programs. 18 We found a strong association between the year of study and likelihood of publishing an article with final year students publishing more articles (32.5%). This trend of publishing status improving with year of study and age is also reflected across the published data 3,10,19 with a British study reporting 70% of the participants who had published were either in fifth year or doing an intercalated degree. 3 This can be a result of increased research courses and educational opportunities in the later years either integrated in curriculum or independent, overtime students are likely to have been exposed to research networks, formed collaborations with peer and senior researchers. 10 By final years students are likely to have aligned their career priorities and maybe better able to invest and manage their time in research activities.
When inquired about the key motivating factors students highlighted improvement of resume 24.6% and personal interest 26.2% as their driving force. These findings match with those in Uganda, 10 Nigeria, 11 and Columbia 19 where participants reported interest in publishing and curiosity as well as having strong role models, personal development, and contribution to patient care.
Pallampathy et al. 20 and Indian 9 studies also reported personal interest but also mentioned factors that contrasted with our findings such as facilitation of foreign exams, and peer pressure as their main motivational factors for research involvement. Improving resumes is an important factor especially in the context of applying to Reflecting on the student inclinations toward journals the majority said 32.2% chose the journal based on journal reputation and 23.5% said based on possibility of acceptance. Studies in LMICs have found students preferring internationally reputable journals due to chances of submission fee waivers, and the added visibility and acknowledgment. 10 Additionally, students fear rejection since journals might prefer articles from experts in the field therefore, it is imperative that high-impact journals should create sections reserved only for students to avoid discrimination based on education level of the author. 23 The main hindrances to not publishing an article were stated as lack of guidance and supervision (31.6%), not having the opportunity to take part in research (30.5%), and being not interested (23.8%) by the students. Indeed, lack of supervision and mentorship has been repeatedly highlighted in Pakistan 2,13,24 and others. 15,16 Also reported in these studies was lack of time and funding. We Another crucial finding in our study was the huge deficit in teaching received by students on writing research papers. Only 18% of our students knew how to critique a paper this is in contrast to Griffin et al. 3 who reported 49% of students being able to critique.
Components should be introduced in the medical curriculum that teach students this critical skill. In an era of highly accessible information, this equips medical students with tools to filter quality information from misinformation to make informed decisions about their patients' care. Similarly, only 30% of students were confident in their ability to write an abstract and 60.4% on writing a paper which is unsurprising considering only 17.7% and 26.4% of the students had been taught how to write an abstract and paper, respectively.
Additionally, we found that students who had been taught how to write a paper and those who knew the process of submitting an article were more likely to get published than the others. Our study is the largest and most recent study to look at publishing practices across Pakistan. We are confident about the accuracy and generalizability of our results because the majority of our responses were from Punjab and Sindh, two provinces with the highest density of medical colleges in Pakistan. However, our study might have some limitations. First, by the nature of study design, our study is a cross-sectional study which is a snapshot in time and therefore not possible to analyze any trends in the publishing practices over the years. Second, it is an observational study and respondents couldn't respond in free text, a future study with this addition can fully encapsulate the sentiments of the students. Third, we relied on students telling us the correct information about their publication status and didn't employ any method to check the accuracy of their claim.

| CONCLUSIONS
Our study has successfully highlighted the status of publishing among medical students in Pakistan. Our findings serve as an eye opener and call to action for authorities to address the grievances of students in terms of barriers, lack of mentorship, and lack of research teaching.
We hope our findings can guide a strong policy change to facilitate the next generation of passionate researchers.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All data are available in the article.

TRANSPARENCY STATEMENT
The lead author Mohammad Yasir Essar affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.